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HomeMy WebLinkAbout2024-00066345 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill OIl III I IIIIIII II 111111111111111111H1 11111 10110 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003590630' u, 1 U2 1 3 4 1 U116 U2 1 U, 1 U2 1 U1 1 U2 1 1 12 U1 14 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066345 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'IT N MCLEAN BLVD ❑ Elgin RELATED ®Y ❑N lU 17 2024 09:47 ®AM ® ❑YES NO u1 .< PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W LAR KI N AVE COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR ❑SLOW 1 Cl, ❑ 'WITH VEHICLES INVLD ❑ STOPPED U2 —1 El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 on DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FOR DAMAGEDAREA(S) FRONT TOWED Ut O 0 8 / 1 8 J 1 9 9 6 Ford F150 2012 00-NONE 11 112 , DUETOCRA 21 SH El (LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE ( _. 2 FIRE 0 IA O < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 lgl U2 m 313 S WESTON AVE F ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 )� 6 II_ COM VEH El El 1 0 1 FTFX1 ET8CFC83781 KEMPER ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 GUTIERREZ,JOSE 12AU001569979 1 `aHOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDER 313 S WESTON AVE, ELGIN , IL,60123 (224)716-0595 VEHU G1 5 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED 0 PEDAL ❑ECUES 0 NUN ❑NCV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 2 m 5 1 2 / 1 7 /2 0 0 4 FOR DAMAGED AREA(S) FRONT E TO CRASH Y N NAME(LAST,FIRST,M) Sanders,Trevon. R. mo day yr Cadillac STS 2005 oo-NONE 1t 12 I 1 0 ® 2 o v 13-UNDER CARRIAGE 10 j 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPDR 17 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3O O X a` 342 PERRY ST M ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE Na STATE YEAR POFIRSNT T COF ONTACT 2 8 I7. I. 6 O C•IO MVEH Sidebar ® U, to C H ELGIN IL 60123 0 EW49919 IL 2024 I 0 f/j, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (708)200-9495 S536-8160-4358 IL D 0 1G6DC67A450232654 PROGRESSIVE ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 985930631 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER E Same Ut = (UNIT) (SEAT) (DOB) ISEX) (SAFT) (AIR) (INJ( (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I / - U2 996 1- m - #OCCS y / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ElY U2 Z N 1 ® 1 1 4 10,17 /2024 09 47 ❑pM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1 T 2 El 32 28 ! / 0 PM ❑Construction * 1 N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 AM ❑Maintenance uz ARREST NAME PENA,STEPHANIE 11-601-Ax w218-894 / / ❑PM SLMT CO11 4 ❑Utility p u 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 30 2 El ARREST NAME / / ppl ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 218-Wilson,Greg 602 272-Bajak , / p PM ®N U2 REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE even if units have been moved prior to officer's arrival. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ' } A CMV is defined as any motor vehicle used to transport passengers or property and. Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer i- 1 ; i r r , , i INDICATE NORTH combination).or —I XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ', ! r r L ' ' 1 ', ' f ` r r r (example'.shuttle or charter bus)-or n S 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----i-----• I I I. .- ' 1 1 1 i .f } - t transporting employees in the course of their employment(example employee transporter-usually a van type vehicle or passenger car).or 03 i r i• 4 Is used or designated to transport between 9 and 15 passengers,including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 71 M CARRIER NAME Z ' .. ADDRESS 0 • N . O CITY/STATE/ZIP . - MOTOR CARR ID ❑ Interstate El Intrastate • ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r---- ----, r r r r r - DO ILCC NO. m U N XI , • Source of above z IDOT PERMIT NO WIDELOAD? ❑Yes ❑No = ' TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m m TRAILER 1 ❑ ❑ ❑ z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. y Black White - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE